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INHALATIONS 



TREATMENT OF DISEASES 



RESPIRATORY PASSAGES, 



PARTICULARLY AS EFFECTED 



$y the \Ut of 3ltomig*d JtoitfsL 



BY 

J. M, DA COSTA, M.D., 

Physician to the Pennsylvania Hospital; Fellow of the College of Physicians; 
President of the Pathological Society of Philadelphia, etc. etc. 




PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

is«;t. 



9 



*> 



Entered, according to Act of Congress, in the year 1807, by 

J. B. LI PPINCOTT <fc CO., 

In the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 



PREFACE. 



This essay appeared originally in the Septem- 
ber and October numbers of the New York Hect- 
ical Journal of the past year. It was intended to 
set forth certain conclusions arrived at regard- 
ing inhalations; to be in fact an expression of 
personal experience on a subject which, though 
it had commenced again to attract some atten- 
tion, was doing so rather in connection with the 
novelty of the apparatus used than from any 
clear ideas of its therapeutic importance. I 
began this inquiry in the spirit simply of exam- 
ining the value of the plan as a clinical prob- 
lem; and satisfying myself of its use in some 
disorders and its futility in others, published 
the results in the form alluded to, adding suffi- 
ciently, as I thought, of the modus operandi to 

( Hi ) 



IV PREFACE. 

allow every physician to test the matter for 
himself. The essay, of which some copies were 
struck for private circulation, seems to have 
attracted much attention, and the copies that I 
had becoming soon exhausted, I have been re- 
quested by my publishers to reissue it to supply 
the demand that is made on them. It stands in 
substance as it was published; here and there 
some additions have been made. 

J. M. Da Costa. 

1005 Spruce Street, Philadelphia. 
February, 1867. 



CONTENTS. 



CHAPTER I. 

The History of Inhalations and the Apparatus employed.... 9 

CHAPTER II. 
The Mode of administering Inhalations 34 

CHAPTER III. 

The Penetrability of Atomized Fluids into the Air-passages. 41 

CHAPTER IV. 
Doses of Medicine for Inhalation 49 

CHAPTER Y. 
Therapeutic Considerations 56 

(t) 



INHALATIONS 



TREATMENT OF DISEASES 



RESPIRATORY PASSAGES. 



CHAPTER I. 

THE HISTORY OF INHALATIONS AND THE APPARATUS 
EMPLOYED. 

The chief materials for this essay were gathered 
during iny term of service at the Pennsylvania Hos- 
pital, though prior to it I had frequently used inhala- 
tions in private practice in laryngeal and pulmonary 
affections. Some of the results obtained — the negative 
as well as the positive — were communicated to the 
class attending the clinical lectures, and, indeed, many 
of the cases were seen by them. But as these results 
were mainly gained by a plan of comparatively recent 
origin, that of atomization, and one the value of which 
can only be settled by the conjoined labor of many, I 
have thought, whether rightly or wrongly, that they 
might be of interest to a larger circle than that which 
witnessed them, and contribute something toward the 
knowledge of the profession on the subject. Let me 
further premise, that a number of the cases which will 
serve as the basis of much which will be said in this 
essay, especially those under my charge at the hospital, 
received no other treatment, and thus I sought to avoid 
a stumbling-block in therapeutic reasoning which often 

2 (9) 



10 INHALATIONS IN THE TREATMENT 

interferes so greatly with our efforts to arrive at defi- 
nite conclusions. 

The attempt to use inhalations in the treatment of 
disease is, as is well known, not a novelty. Are- 
tseus employed them, and with Galen they were a 
favorite mode of treatment. Indeed, with all Roman 
physicians they became so ; and both by the physicians 
of antiquity and later by the Arabs the inhalation of 
sulphurous vapors in bronchial affections, and of arsen- 
ical vapors in asthma, was constantly advised — the 
latter a prescription which, in our own times, has been 
revived by Trousseau. Hot, dry air was strongly 
recommended for the cure of consumption by Piso, in 
1580; and Bennet, a London physician, living about 
the middle of the seventeenth century, directed his 
patients to breathe the atmosphere of a chamber filled 
with fumes of medicinal substances, especially of the 
gum-resins. Several authors of the sixteenth and 
seventeenth centuries lauded camphor, amber, myrrh, 
sulphur, assafetida, and the balsams for the purposes 
of inhalation; and Benedict* employed them in con- 
sumptive diseases. Boerhaave and Yan Swieten used 
inhalations in the early part of the eighteenth century; 
and Boerhaavef gives several quite explicit formulas. 
Mead J advises that the balsamic ingredients for inhala- 



* Theatrum Tabidorum. f Materia Mediea. 

J Monita et Precept a. 



OF THE RESPIRATORY PASSAGES. li 

tion should be thrown on red-hot coals, and the fumes 
received through a proper tube directed to the wind- 
pipe, and praises highly the smoke thus conveyed into 
the lungs, when produced by balsam of Tolu. 

But it does not appear that any of these endeavors 
to employ inhalations were particularly successful, and 
they had fallen into disrepute, when the detection of 
oxygen and other elementary gases led to the mode of 
treatment being revived by Beddoes. Yet the exag- 
gerated statements with reference to its action, the un- 
certain effects, and the attempt to make inhalations 
serve the purpose of a panacea, produced again, very 
naturally, an utter want of confidence in them, which 
was only disturbed by the discovery in this century of 
iodine and chlorine. These agents were eagerly seized 
hold of by those physicians who had not lost all faith 
in inhalations, — and prominent among them we find 
Scudamore and Piorry, — partly with the view of act- 
ing on affections of the respiratory organs ; partly be- 
cause a better knowledge of physiology was teaching 
that we may make use of these organs to modify 
the blood, and thus alter the condition of the whole 
system. Though here, too, we find that a practical 
application of this view had already for some time been 
made ; for Fracastori* records that the fumes of cinna- 
bar were much employed by inhalation in the treat- 

* See Copland's Dictionary. 



12 INHALATIONS IN THE TREATMENT 

ment of the constitutional forms of syphilis, at an early 
period of the history of that affection, when it assumed 
a pestilential form. 

The results obtained by chlorine and iodine were to 
a certain extent successful ; and the same may be said 
of the inhaling of the fumes of belladonna and stramo- 
nium, of turpentine, of tar, urged by Crichton and 
Sir John Forbes, and of the vapors of muriate of am- 
monia — all of which are still recommended by men of 
eminence in our midst, and are to this day resorted 
to, particularly in asthma and in bronchial affec- 
tions, while turpentine has been warmly eulogized by 
Skoda, in gangrene of the lungs. Little if any good 
followed the use of inhalations in consumption, and it 
was perhaps from being so generally disappointed in 
their action in this complaint that the profession 
allowed inhalations to be in the hands of quacks, 
who, pandering to the popular feeling that remedies to 
affect the lungs ought to be addressed to them, availed 
themselves of these agents to allure and to deceive. 
This was strikingly shown by the use the versatile 
charlatan St. John Long made of inhalations, which, 
conjoined to his liniment, formed that treatment 
through which he became the pet of the fashionable 
circles in London, and particularly of the female por- 
tion. In the room of the handsome adventurer were 
two enormous inhalers, placed in the interior of a large 
mahogany case resembling an upright piano. From it 



OF THE RESPIRATORY PASSAGES. 13 

flexible tubes ran in all directions, at which numbers of 
persons were eagerly drawing, while dozens of excited 
women, of all ages, were waiting until a mouth-piece 
should be at liberty.* And all over the world were 
men who, more or less closely, and according to their 
powers, copied the do!ngs of this ignorant pretender, 
and have continued until now to do so. 

The kind of inhaler which was mostly made use of by 
the profession for the inhalation of some of the articles 
mentioned, as of tar and turpentine, and even at times 
of iodine and chlorine, consisted of the simple instru- 
ment still employed for the purpose: a wide- mouthed 
bottle, with its cork perforated for two glass tubes ; the 
one passing below the level of the medicated fluid, the 
other, or the one through which the patient inhales, 
immediately above the level. This form of apparatus 
may yet be very serviceably resorted to for the inhala- 
tion of turpentine, of tar vapor, and of carbolic acid. 
An apparatus, suitable alike for the inhalation of moist 
and dry vapors, and arranged to insure their ready dis- 
engagement, was suggested by Dr. Snow;f and a 
similar apparatus has been recently much employed by 
Mandl in treating chronic bronchitis. J 

Such, then, is an outline of the history of inhalations 

* A Book about Doctors, by Jaeffreson. 1860. Chapter '-St. 
John Long." 

f London Journal of Medicine, vol. iii. 
I See Still^'s Therapeutics, vol. i. p. 64. 

2* 



14 INHALATIONS IN THE TREATMENT 

by vapors and gases. But there were some practition- 
ers of good repute who endeavored to bring solids and 
fluids in contact with the diseased membranes. This, 
too, or at all events the use of powders by insufflation, 
had its origin among the physicians of antiquity, 
though the most systematic attempts to accomplish 
this purpose belong to the present day, and insuffla- 
tions of alum, of nitrate of silver, and other articles, 
through tubes so curved that they could be passed as 
far as the larynx, have been frequently tried. These 
attempts w r ere greatly stimulated by finding that, in 
those whose occupations expose them to it, minute 
particles traverse the bronchial tubes and become im- 
bedded in the lungs, as has been proved to be the case 
in the phthisis of coal miners, and knife-grinders, and 
millstone makers.* Moreover, we know that those 



* See particularly a case by Peacock, in Brit, and For. Med.- 
Chir. Review, Jan. 1860; and on the coal miner's lung, Green- 
how, in Transact, of Path. Society of London, 1865. Elaborate 
papers on the subject have just appeared by Zenker, and by 
Seltmann in Deutch Archiv fur Klin. Med., quoted in Schmidt's 
Jahrb. No. 11, 1866. 

Quite recently my attention has also been called by Dr. Flem- 
ing, a very intelligent physician of Pittsburg, and formerly a 
resident physician in the Pennsylvania Hopital, to the rapidity 
with which men repairing copper-work which has been used 
for steam, water, etc. become affected by the impalpable oxide 
of copper therein formed. He adds in his letter: "Exposed 
myself for a few minutes to the same influence, and the quan- 
tity breathed exceedingly minute, I was astonished at the 
great effect I experienced: constriction about the chest, most 
active salivation, etc." 



OF THE RESPIRATORY PASSAGES. 15 

who talk most while exposed are most subject to pul- 
monary complaints ; for among gunsmiths and work- 
ers in steel we are told that the ones who suffer most 
are "les ouvriers bavards et ceux qui ont l'habitude de 
chanter en travaillant."* But, notwithstanding these 
proofs that the lungs can be reached by pulverized sub- 
stances, and the zeal with which the subject of insuffla- 
tion of powders has been pursued by several observers, 
it cannot be said to have shown itself of much use 
therapeutically. Indeed, its only demonstrable value 
has been in cases of laryngeal disease. 

The same may be said of the application of fluids to 
the disordered mucous membranes, as was so constantly 
and so skillfully done by Dr. Horace Green. Service- 
able beyond all doubt in affections of the larynx, their 
injection into the bronchial tubes has not a very wide 
range of utility. For, besides the great difficulty of 
accomplishment, the diseases to which this mode of 
practice is suited are not many, and the certainty that 
the liquid reaches the really affected parts is not great. 

Thus, then, neither vapors and gases, nor solids, nor 
fluids yielded results that could be looked upon as 
encouraging with regard to the topical treatment of 
diseases of the organs of respiration. Nay, if we 
except the inhalation of the vapors of tar and turpen- 
tine, and a few others above mentioned, the whole sub- 



* Gu^rard. Comptes Rendus de la Societe d'Hydrologie 
M^dicale. 



16 INHALATIONS IN THE TREATMENT 

ject was receiving very little attention from the profes- 
sion, until a plan of breaking up fluid into very fine 
particles was proposed by Sales Girons. This has re- 
opened the whole question in how far a local treatment 
of the disorders alluded to is beneficial or likely to suc- 
ceed. But, whatever be the verdict on this point — 
and it is one of the chief objects of this essay to aid in 
contributing toward that verdict — it is certain that in 
the formation of a fine spray, or " pulverization of 
fluids," or "nebulization," or "atomization," we have 
gained a therapeutic means of value, which has an 
applicability much wider than merely to the treatment 
of the respiratory maladies, and which henceforth will 
be employed, though it be rejected for the purpose for 
which it was originally intended. 

The first experiments of Sales Girons were crude. 
They were carried on in a room set apart at a watering- 
place. The mineral water, either in its natural state or 
impregnated with various medicinal substances, was 
projected through a tube with great force by means of 
an air pump placed in an adjacent apartment. As the 
stream filled the tube the fluid was forced out of six or 
more capillary openings, and, impinging against the 
surface of a metallic disk, was broken up into a mist, 
which the patients — for several inhaled at the same 
time — breathed. Though protected by appropriate 
garments, no sick person relished much the dampness 
and inconvenience of the whole procedure — one, it may 



OF THE RESPIRATORY PASSAGES. IT 

be mentioned, in passing, very similar to the previous 
attempt of Auphan at Lamotte-les-Bains, and differing 
chiefly in the fluid not being dashed directly against 
the walls of the apartment where it was pulverized, 
much in the Avay as a waterfall which strikes against 
the rocks is broken up into spray. Unless, then, some- 
thing more convenient could be discovered — some ap- 
paratus which was portable, easily managed, and yet 
atomized fluid very finely — the experiments would not, 
in their practical application, have been of much value. 
After repeated trials, this was successfully accomplished 
by Sales Girons, and others have since followed in his 
footsteps. I shall briefly describe these instruments, of 
which now many forms exist, particularly such as I 
have found to be of most service, pointing out what I 
believe to be the chief merits and defects of each. 

The first of the portable kind, projected by Sales 
Girons and made by Charriere, consists of a vessel in 
which the fluid to be atomized is poured, and which is 
attached to an air pump placed above it. The air, 
compressed on the surface of the fluid, drives this 
through a very fine opening, arranged with a stop-cock, 
against a small metallic disk, where very minute spray 
is formed. The condensed fluid passes off through a 
gutta-percha tube. The amount of pressure is indi- 
cated by a manometer. A pressure of from three to 
five atmospheres is sufficient. A modification of this 
apparatus, in which the vessel is made of glass instead 



18 



INHALATIONS IN THE TREATMENT 



of metal, is generally known as the second model of 
Sales Girons. But Sales Girons himself has recently 
greatly simplified his whole apparatus, left out the 




Fig. 1. — The Original Apparatus of Sales Girons. 

manometer, and made the instrument lighter and very 
much easier of employ. It consists of a pump which 



OF THE RESPIRATORY PASSAGES. 



19 



forces the liquid through a fine opening in an inge- 
niously arranged stop cock against a metallic disk, as 
in the other nebulizers. The opening in the stop-cock 




Fig. 2. — The New Atomizer of Sales G irons. 



can be increased or diminished in size by simply turn- 
ing it in a backward or forward direction, and a very 
tine spray is undoubtedly obtained by this instrument. 
The first-mentioned model of Sales Girons is now but 
little used ; but it has an historical value, since on the 
same principles many others have been constructed — 
for instance, the atomizers of Fournie, Waldenburg, 
and Lewin. The latter instrument has a very great 



20 



INHALATIONS IN THE TREATMENT 



advantage in its consisting chiefly of glass : the tube 
through which the medicated fluid passes is of glass, 
the disk against which the stream of fluid strikes in the 
cylinder of glass is gilt, and thus is unquestionably 
avoided one of the most serious objections to the atomi- 
zers of Girons, and which renders them unfit for the use 
of chloride of iron, nitrate of silver, and other articles 
that act on metal. 

On a similar principle as the last model of Sales 
Girons is a nebulizer, in which the pump works by a 



~" ---:.. ';.. o.. e\ 



U'tXtf 




Fig. 3. — The Pump Nebulizer. 



long handle, and the fine stream impinges against the 
side of the cylinder, but not against a metallic disk. I 
think this apparatus was originally made by Matthieu ; 
and to it, as well to the last invented one of Sales 



OF THE RESPIRATORY PASSAGES. 21 

Girons, may be attached a little tube, through which a 
capillary jet passes with such force that it penetrates 
the skin, and may be used to inject medicines hypo- 
dermically. 

In all the instruments alluded to the fluid is forced 
by strong pressure against some firm body, where it is 
broken up into very fine particles. But another prin- 
ciple has been made use of to accomplish this purpose, 
namely, the action of a current of air compressed in a 
large ball, and which, intermingling with the fluid, 
changes this into a minute spray as it rushes out of a 
capillary opening. This instrument, the "Nephogene" 
of Matthieu, is handled with readiness ; but it is apt to 
get out of order, and the spray is thrown with greater 
force than is usually advisable ; moreover, a large 
quantity of atmospheric air is projected into the air- 
passages with it. A far better application of using a 
current of air as the means of atomizing the medicated 
liquid was made by Dr. Bergson, by employing the 
same kind of tubes as are now so extensively sold as 
odorators, for the pulverization of different scents. Two 
glass tubes, with capillary openings, are placed at right 
angles to each other, in such a manner that the end of 
the vertical tube is very close to and about opposite the 
centre of the capillary opening in the horizontal tube. 
Through this the air is blown while the vertical tube is 
dipped in the fluid to be atomized. The air in the latter 
tube is rarefied; the liquid rises to the capillary open- 

3 



£9 



INHALATIONS IN THE TREATMENT 



ing and is there pulverized by the current of air from 
the vertical tube. Two tubes properly arranged are 
then all that is strictly required for this simple appa- 
ratus, for the air may be blown by the mouth through 
the horizontal tube. But in point of practice this pro- 
cedure is both irksome and unpleasant, and to avoid it 
an ordinary Davidson's rubber syringe may be attached 
to the horizontal tube; or, better still, a continuous 




Fit*. 4. — Tae Hand-bull Atomizer. 

stream may be obtained, as proposed by Bergson, by a 
bellows connected with an air chamber. The bellows 
is worked by the foot. Yet more convenient is a similar 
arrangement of Andrew Clark, consisting of two balls, 
the lower of which is pressed by the hand, and the 
upper of which, surrounded by a silk network, acts as 
an air chamber. 



OF THE RESPIRATORY PASSAGES. 23 

The principle of Bergson is distinguished by great 
simplicity, and is very readily applied. The tubes may 
be made of silver or of glass. Those of the latter are 
generally preferable. They are much more easily kept 
clean, and can be used with articles which corrode the 
former. On the other hand they are more easily broken. 
Tubes of glass can be kept clean by soaking them oc- 
casionally in muriatic acid and water, or pulverizing a 
little of this mixture through them. If the tubes be- 
come clogged, a bristle or a very delicate metallic wire 
is the best means of removing the obstruction. A pin 
or a needle is apt to break the fine points. The tubes 
may be made of any length or calibre. To produce a 
delicate spray, the openings at the ends, where placed 
in juxtaposition, ought to be very small. The hole in 
the horizontal tube may be somewhat larger than the 




Fig. 5. — Bergson's Tubes of modified shape, united by an India-rubber band. 

capillary opening in the vertical tube. A modifica- 
tion in the shape of the tubes, as seen in Fig. 5, was 
proposed by Prof. Winterich, and is often of great 
service. By this arrangement we can generate the 



24 INHALATIONS IN THE TREATMENT 

spray within various parts of the body. I have had 
tubes of the kind made of all sizes and of different 
curves — to pass up the nostril, as in the treatment of 
catarrh ; to place in the ear and reach the membrane 
of the tympanum ; to apply near the back of the throat, 
or immediately over the entrance of the larynx — thus 
furnishing a far better means for local treatment than 
the ordinary sponge probang, and even better than the 
laryngeal fluid pulverizer of Gibb. If it were judged 
expedient as a therapeutic means, they could be so 
shaped as to throw a spray even into the interior of the 
uterus or bladder. 

Similar in some respects to the arrangement just 
mentioned is Maunder's spray producer. The an- 




Fig. 6. — Maunder's Laryngeal Spray Producer. 

nexed wood-cut shows that it consists of an India- 
rubber bottle perforated at the base so as to admit, 
when emptied, of instant refilling with air; of an 
upper or air tube communicating at one end with the 
bottle and terminating at the other in a capillary open- 
ing; of an under or medicine tube dipping at one end 



OF THE RESPIRATORY PASSAGES. 25 

into a medicine glass and ending at the other in a 
capillary orifice. 

Bergson's tubes are also employed in an atomizer, 
invented by Dr. Oliver, of Boston ; though here the 
spray is still further broken up and converted into a 
fine mist by impinging against the walls of the glass 
vessel in which the tubes are contained. At the same 



Fig, 7.— Oliver's Atomizer, as made by Codman & Shurtleff, Boston. 

time the face is by this arrangement completely pro- 
tected. For the use of caustic solutions, and where it 
is desirable to atomize only small quantities of the fluid, 
this form of atomizer claims several advantages. 

The instrument arranged by Richardson for local 
anaesthesia is a modification of the hand-ball atom- 
izer. The principle of Bergson is employed, with the 
addition of that of pressure caused by air forced at 
the same time into the bottle by the air bag. The air 
and the liquid are jetted out together from the orifice 

3* 



26 



INHALATIONS IN THE TREATMENT 



of exit, and thus the spray is produced. With ether of 
specific gravity of *720, or less, the part may be frozen 
by working the apparatus about one minute, and with 
rhigolene — the fluid introduced by Dr. Bigelow — in 
from 5 to 15 seconds. The pain produced by rhigo- 
lene is, I am informed by Dr. Keen, who has made a 
number of comparative experiments on the subject, 
very much less than that caused when ether is em- 
ployed ; which, in truth, occasions often almost insup- 
portable suffering. Rhigolene, it may be added, is not 
used with Richardson's tube, but with metallic tubes 
on the Bergson principle ; and the apparatus for either 
agent may also be made available as an ordinary spray 
producer in the treatment of throat affections. 




Fig. 8. — Richardson's Spray Producer. 

But to return to atomizers proper : we have dis- 
cussed those in which air acts as the forcing power, or in 
which the fluid is driven by a piston through a narrow 
opening. They require, of course, a certain amount of 
exertion on the part of the patient, or an assistant. 
This is obviated in the ingenious apparatus of Siegle, 



OF THE RESPIRATORY PASSAGES. 



27 



who substituted steam as the motive power. Adopt- 
ing the arrangement of tubes of Bergson, he has added 




Fig. 9. — Wood-cut illustra- 
tive of the interior arrange- 
meut of Richardson's spray 
producer, a, adjustable con- 
ical cap ; e, hollow curved tube 
containing within capillary 
tube, and this near its upper 
extremity perforates cylinder 
of metal b; d, tube to be at- 
tached to the India-rubber 
tubing. The tubes in this ap- 
paratus, as made by Tiemann 
& Co.. N. Y., are of silver. 



a small boiler, made of metal or of glass, in which 
steam is generated by means of a spirit lamp. The 
steam plays the part of the compressed air, and as it 
escapes projects as a tine spray the liquid placed in the 
cup. The degree of pressure is indicated by a thermo- 
barometer, marked 1 and 2. It is safe enough to let 
the mercury range between 1 and 2 ; above this there 



28 INHALATIONS IN THE TREATMENT 

is some danger. By lowering the flame the steam is 
generated with less rapidity and force. A small lamp 
under the glass cup containing the medicated fluid heats 
this, and thus the inhalation may, if necessary — which, 
however, it extremely rarely is — be given very warm. 
Fig. 10 represents Siegle's apparatus in its most perfect 




Fig. 10. — Siegle's Large Atomizer. 

form. In addition to the thermo-barometer we find a 
safety-valve. 

Now, on Siegle's principle, numerous instruments 
have been constructed. The size of the apparatus, its 



OF THE RESPIRATORY PASSAGES. 29 

shape, the lamp, have been modified; but few of the 
modifications are really improvements. It may, how- 
ever, for ordinary purposes, unquestionably be much 
simplified ; and Mr. Gemrig, an instrument maker of 
Philadelphia, has constructed, according to a design I 
gave him, a steam atomizer, which is both simple and 
very convenient. It consists of a copper boiler, with a 
spring safety-valve in place of the thermo- barometer. 
By unscrewing the safety-valve the water can be poured 
into the boiler. This fits into a metallic tube, at the 




Fig. 11. — Siegle's Apparatus, with water-gauge (B) and valve (F), as modified 
by Krohne, and made by Otto & Reynders, N. Y. 

bottom of which a spirit lamp is placed, the flame of 
which can be heightened or lowered. The atomizing 
tubes are inserted into a cork, or a perforated piece of 
gutta-percha, which is readily fastened by a metallic rim 



30 



INHALATIONS IN THE TREATMENT 



with a bayonet catch. In some of Siegle's instruments 
this point is omitted, and the cork or piece of rubber is 
liable to be blown out when the steam is generated. 
In his largest apparatus (Fig. 10), screws hold down 
the India-rubber at two of the openings. Leaving 
out the thermo-barometer is, in any apparatus, except- 
ing those for purposes of very accurate study, a great 
gain. It is irksome to the patient to be constantly 
watching it while inhaling, and is apt to get broken. 





Flu. 12. — Simple form of Steam 
Atomizer. 



Fig. 13. — Boiler with Tubes attached 
and spring safety-valve. 

The simple apparatus just 
described is shown in Fig. 
1 2 ; its component portions 
are seen in Figs. 13, 14, 15, 
and 16. When in action, 
the boiler should be about two thirds full of water, 
and after the medicated fluid has been pulverized, the 
tubes should be cleansed by letting the instrument 
nebulize pure water. 

As the various apparatuses for atomizing liquids have 
been passed in review, — and in so doing I have en- 



OF THE RESPIRATORY PASSAGES. 



31 



deavored to describe rather the different principles that 
have been suggested for their construction than at- 
tempted to give a complete list of all the instruments 





Fig. 15. — Lamp, with 
screw to raise or depress 
the wick. 



Fig. 14.—- Metallic ti be 
at the npj er p: rt of which 
the boiler is placed and 
at the lower part the 
lamp. 




Fig. 16. — Cup for medi- 
cine, and it st witb slide to 
hold it. 



which have been proposed, — I may now state what I 
believe to be their relative efficiency. The most per- 
fect as well as the most efficient is that of Siegle, or 
some of those framed on his plan. The steady stream, 
the possibility of working the apparatus without fatigue 
and without an assistant, the small quantity of medi- 
cated fluid required — while in most of those which are 
set in action by a pump the quantity is very great — are 
all features of pre-eminent value. Then the minute 
division of the fluid and the warmth of the spray that 
reaches the respiratory organs are also points of de- 
cided consequence. But under some circumstances 



32 INHALATIONS IN THE TREATMENT 

other atomizers will answer better; for instance, in the 
treatment of affections of the throat or nares, or even 
in man}^ of those of the larynx, the nebulizer depicted 
Fig. 3, or Maunder's, or Bergson's tubes with the bel- 
lows attached, may, for the most part, be more easily 
and advantageously employed. Again, this apparatus 
may be resorted to when the patient is in the recum- 
bent position; when he lies in such a manner that an 
instrument with a lighted lamp cannot with safety be 
placed near him ; when the heat of the weather renders 
it annoying to use a steam apparatus; when a cold 
rather than a warm inhalation is therapeutically de- 
sirable; when, on account of the time lost, it is incon- 
venient to have to generate steam ; or when the patient 
is careless, or not intelligent enough to learn to use an 
apparatus which requires both care and some intelli- 
gence to use properly. Then, in very many cases, par- 
ticularly those of affections of the fauces and windpipe, 
the quantity of medicated fluid necessary is but small, 
as, for example, when solutions of caustic are required. 
And here the hand-ball atomizer or some of its modifi- 
cations will be found very convenient. Indeed, I think 
that, excepting the steam nebulizer, it is the best form 
of spray producer — superior to that of Sales Girons, 
and to the one depicted in Fig. 3 ; and for the purposes 
just alluded to it is even better than the steam atomizer, 
while its ready use and portability, the fact that the 
fluid can be injected without any or with but slight co- 






OF THE RESPIRATORY PASSAGES. 33 

operation on the part of the patient — in children espe- 
cially a very great advantage — and the manifold employ 
to which it can be put, are additional recommendations. 
Yet it cannot be said to take the place of the steam 
atomizer in the treatment of diseases of the lung. It 
becomes too irksome and fatiguing to work it long 
enough to produce the quantity of spray required for 
each inhalation. 



34 INHALATIONS IN THE TREATMENT 



CHAPTER II. 

THE MODE OF ADMINISTERING INHALATIONS. 

But whatever apparatus be employed, there are 
some points to be observed in the use of inhalations, 
the neglect of which will seriously interfere with the 
benefit to be derived from them, and may, indeed, 
cause them to be abandoned in disgust. And, in the 
first place, we should instruct our patient in the appli- 
cation of the instrument, show him how to keep it 
clean, how r to tell when it is working properly. This 
implies that he should have one in his possession. In 
truth, excepting when resorted to in certain affections 
of the larynx and fauces, or for a mere temporary pur- 
pose, and particularly when required in chronic dis- 
eases of the lungs, the inhalations ought not to take 
place at the physician's office. The patient must em- 
ploy them once or several times daily, and unless he 
can attend to them himself, in the same manner as he 
knows how to take his tonic pill or his cough mixture, 
the treatment will be inefficient. It is evident, then, 
that he must, as a rule, carry on the treatment at his 
own house. At the first inhalation the physician ought 
always to be present. 



OF THE RESPIRATORY PASSAGES. 35 

When the patient is ready for the inhalation, he 
should sit in front of the apparatus, in a convenient 
position, and in such a manner that the spray is formed 
on a level with his mouth. The mouth must be kept 
wide open and the head be slightly inclined backward. 
The distance proper to sit from the spray-producing 
tubes varies. When he begins the inhalation, he ought 
to be about six inches from them. This distance may 
be increased from one to two feet, according to the ob- 
ject we have in view. If we wish the patient to inhale 
a large quantity of the spray, and at a comparatively 
high temperature, let his mouth be near to the appara- 
tus. And we direct him to take deep breaths when 
we desire to reach the bronchial tubes and more dis- 
tant portions of the respiratory channels, while we 
insist upon shallow breathing if our intention be to 
act on the fauces and upper part of the air-passages. 
But under no circumstances should he breathe in such 
a manner as to be fatiguing to him ; and it will be 
often necessary to restrain him from respiring with 
much effort and hurriedly. 

In persons with sensitive mucous membranes the 
act of inhalation causes considerable cough. But even 
this can ordinarily be avoided by letting them breathe 
at first the spray warm and close to its point of pro- 
duction, and by commencing with inhalations of pure 
water. In most cases, after a few inhalations, no 
cough is produced ; nay, strange to say, coughing is 



36 INHALATIONS IN THE TREATMENT 

more apt to occur when the inhalation is over than 
while in progress. 

A point always to be attended to is to see that the 
tongue is not in the way of the current, and that the 
spray can really reach the back of the throat. It is 
well to direct the patient to press his tongue against 




Fig. 17.— Face Shield. 



the floor of the mouth. If he cannot easily do this, a 
tongue depressor may be employed ; but I have found 
it more advantageous to insert a short small glass 
speculum, from three to four inches in length, into the 
mouth. This keeps the tongue out of the way, and 
yet he can breathe very readily through the tube. To 
prevent the face from becoming wet, a face shield may 
be employed, preferably made of glass or wood. It 
can be held by the patient, or attached to the atomizer, 
as it is in the very serviceable instruments made by 
Dr. William Read, of Boston ; or fixed near to it in 



OF THE RESPIRATORY PASSAGES. 37 

shape of a screen, as suggested by Dr. Beigel; or 
placed on a movable supporter in front of the appara- 
tus, as is done by Codman & Shurtleff, of Boston, in 
the excellent, safe, and durable steam atomizer they 




Fig. 18. — Steam Atomizer of Codman & Shurtleff, with face shield. 

make. In any case the shield can be so arranged with 
a depressed rim, into which a gutta-percha tube is 
fixed, that the drops of fluid which collect flow into a 
glass. But I find that patients often prefer dispensing 
with a face shield. It is, of course, always necessary 
to protect the clothes with a napkin or towel, and to 
have a vessel at hand into which any of the fluid w r hich 
may accumulate in the mouth can be expectorated. 

As regards the frequency and the time of the inhala- 
tions, it is difficult to lay down general directions. But 
this much is certain : for the treatment to be effective, 
the patient should inhale daily, and breathe the medi- 
cated spray for about ten minutes or longer, taking in 

4* 



38 INHALATIONS IN THE TREATMENT 

that time about one hundred respirations or more, and 
resting for some seconds after inhaling continuously for 
a few minutes. In many cases it is better to have him 
inhale twice or three times daily; and it is always, 
perhaps, more convenient to let him inhale a certain 
quantity, say one ounce of the medicated fluid, than to 
annoy him by directing him to count the frequency of 
the act of breathing. With a well-constructed steam 
atomizer, the time of each inhalation should be from 
ten to fifteen minutes, and about the same time is 
required at each sitting with the nebulizer of Sales 
Girons, or any of those working with a pump. The 
first inhalations ought always to be short, so as to 
accustom the patient to them : and it is astonishing 
how, though they irritate him at the beginning of the 
treatment, he becomes less and less sensitive to them. 
The patient ought never to inhale on a full stomach, 
and should abstain from going out of doors for a quar- 
ter of an hour after the inhalation. 

In these remarks I have had chiefly reference to the 
treatment of pulmonary affections, and secondarily to 
that of laryngeal diseases. But as the form of thera- 
peutics under consideration applies also to disorders of 
the fauces and adjacent structures, I may briefly indi- 
cate in what manner the mode of procedure is to be 
modified in their treatment. The inhalation is of 
shorter duration, and need not, excepting in certain 
urgent cases, be done so frequently. The greatest care 



OF THE RESPIRATORY PASSAGES. 39 

should be exercised to cause it to reach the affected 
spot ; and to effect this I have often found the method 
above mentioned, by passing the current through a 
small glass speculum introduced into the mouth, very 
efficient. It has, moreover, the advantage of bringing 
the diseased surface thoroughly into view, and of limit- 
ing the action of the pulverized fluid much more com- 
pletely to it. When the spray is thus passed through 
a speculum, and even, if the tongue be not in the way, 
by simply directing the jet to the affected textures, we 
can obtain results which are not attainable by means 
of ordinary local applications. The spray reaches 
parts more readily than the probang, and in certain 
cases produces a preferable and more permanent action. 
Its superiority over gargles is manifest, touching struc- 
tures never or but scantily reached by these, as for 
instance the posterior wall of the pharynx ; so striking 
is this superiority, that for really useful purposes the 
day of gargles has passed. Even in enlargement of 
the tonsils, I have used pulverized fluids with consider- 
able success. In one case, particularly, that of a little 
boy greatly troubled with chronic pharyngitis and en- 
larged tonsils, and liable on any exposure to acute 
exacerbations, they effected a cure which no other 
means could have accomplished. Each attempt to 
reduce by caustic or astringent solutions the tonsils, 
which nearly blocked up the half arches, was a signal 
for an outburst of passion and for violent resistance on 



40 INHALATIONS IN THE TREATMENT 

the part of the child. To the treatment by pulverized 
fluids, such as of strong solutions of tannin, he sub- 
mitted without objections. 

Let me add, in concluding the mode of inhalation 
and the modification necessary to adapt it to individual 
parts, that the force of the current is an element also to 
be taken into account. A very strong current is not 
suitable for pulmonary affections; it is more suitable 
for those of the fauces. The spray projected with too 
much force is apt not to enter the air-passages, but to 
condense on the walls of the throat. 



OF THE RESPIRATORY PASSAGES. 41 



CHAPTER III. 

THE PENETRABILITY OF ATOMIZED FLUIDS INTO THE 
AIR-PASSAGES. 

In the preceding considerations, and while discussing 
the mode of applying the medicated spray, it has been 
assumed that this can be made to reach not only the 
fauces and pharynx, but the respiratory channels. 
Now, with reference to the former point there can be 
no question; but much skepticism has prevailed as 
regards the entrance into the air tubes of the pulverized 
fluids ; and before passing on to indicate the uses of 
these agents, it is incumbent to inquire into the evi- 
dence on which it has been assumed that they pene- 
trate into the lungs, or even into the larynx. Xot to 
mention further the well-known facts alluded to in con- 
nection with the coal miner's lung, and which have a 
strong bearing on the subject, the evidence of fine par- 
ticles reaching the air-passages is of two kinds : first, 
that furnished by demonstrative experiments made on 
animals and man ; and, secondly, that attained by 
perceiving the effects of inhaling the atomized liquid, 
particularly its prompt effect in producing or allaying 
spasm, in checking hemorrhage and the like. 



42 INHALATIONS IN THE TREATMENT 

To the first categoiy belong the interesting experi- 
ments of Demarquay, which, repeated in the presence 
of Poggiale, were used bj- him as the basis of his able 
report to the French Academy. Dogs and rabbits, 
with their mouths forced open and their nostrils closed, 
were made to inhale for five minutes a pulverized solu- 
tion of perchloride of iron, of the strength of 1 part of 
the iron to 100 of distilled water. The animals were 
afterward killed, and throughout the larynx, trachea, 
bronchial tubes, and even in the lung structure, the 
presence of the persalt of iron was clearly detected by 
the production of Prussian blue with the ferroc}^anide 
of potassium and acetic acid. But it was objected to 
these experiments that they were made on animals, 
and that all the circumstances were such that it was 
unfair to infer that the same results could be obtained 
in man. To meet these clamors, Demarquay ex- 
perimented on a nurse at the Hospital Beaujon, 
who breathed through a canula in her trachea. She 
inhaled a pulverized solution of tannin while the 
tracheal opening was closed with a slip of paper, 
moistened with a solution of perchloride of iron, and 
held in place by means of a strip of sticking-plaster 
and a napkin. After inhaling for a minute, the stick- 
ing-plaster and the paper were removed, and a piece 
of paper impregnated with a solution of perchloride 
of iron was pressed, with the aid of a delicate forceps, 
into the trachea. In the first two experiments there 



OF THE RESPIRATORY PASSAGES. 43 

was no reaction ; in the third, the black discoloration 
of the paper proved that the solution of tannin had 
entered the air-passages. Fieber,* in Vienna, repeated 
the experiment on a man twenty- two years of age. 
It only succeeded on the fourth attempt. A few 
months since I tried it three times on a man about 
twenty-six years of age, a patient under my charge at 
the Pennsylvania Hospital. He had cut his throat in 
an attack of mania a potu three months before he came 
under my observation, and wore a canula. I made 
him, after removing the canula, and while closing the 
tracheal opening with the finger, as done by Demar- 
quay in his third, the successful experiment, inhale, for 
nearly two minutes, and by means of a steam atomizer, 
compound solution of iodine, 15 drops to the ounce, 
and then passed a thoroughly starched linen rag into 
the opening. No satisfactory reaction was perceived ; 
neither was it when a canula, covered on its upper sur- 
face with a starched piece of linen, was employed. 
Nor was an experiment with tannin and chloride of 
iron more successful. A laryngoscopic examination 
showed the cause of failure. The false vocal cords 
were tumid, greatly engorged, rigid ; and the motion 
of the cords was hardly perceptible even when the 
man, w r hile the tracheal opening was closed, was doing 
his best to breathe through the mouth. They were 

* Die Inhalation, etc., 1865. 



44 INHALATIONS IN THE TREATMENT 

scarcely dilatable, though after a course of laryngeal 
catheterization they became so. 

The difficult success of Bemarquay and Fieber, the 
total want of success of Fournie, who experimented on 
the case of Demarquay, w x ere chiefly due to the great 
obstacles in completely closing (owing to the anatomi- 
cal relations of the parts) the tracheal opening — an in- 
dispensable condition for preventing the experiment 
from being a vain one ; and to the inability of the 
patient to remain but for a very brief period deprived 
of the canula. In this respect my case was better 
suited, yet it presented other and greater hinderances. 
In truth, a union of all conditions favorable to com- 
plete success is rare ; hence, while we may claim the 
positive results obtained as conclusive, the failure to 
obtain these results, it is evident, is not equally so. 

Still, though we can very rarely on man demonstrate 
to the eye the passage of atomized fluids down the 
trachea, it is easy to satisfy ourselves of their entrance 
into the larynx. This observation which I have made 
will prove it. Let a person inhale pulverized distilled 
water, to which some drops of a solution of blue or 
red aniline have been added. Let him then be imme- 
diately examined with a laryngoscope ; an intense 
color, visible on the vocal cords and at the beginning of 
the trachea, will show where the aniline has reached. 
Bataille,* inhaling a solution of rhatany, noticed on 

* Gazette Hebdom., 1862. 



OF THE RESPIRATORY PASSAGES. 45 

himself, by means of the laryngoscope, the red discol- 
oration of the larynx and trachea. He also expecto- 
rated for a whole day subsequently a reddish sputum, 
which, from its character, he believes to have proceeded 
from the bronchial tubes. 

Yet another demonstration of the penetration of the 
atomized liquid is furnished by post-mortem inspection 
of pathological processes. A number of the rabbits 
Demarquay experimented on, and which were not fur- 
ther interfered with after they were made to breathe 
the solution of the perchloride of iron, died of pneumo- 
nia, generally of very circumscribed kind. Trousseau 
reports the same consequence from inhalations of tan- 
nin in a lady, who, finding herself benefited by them, 
inhaled for several hours daily until a fatal pulmonary 
inflammation supervened. Still more significant are 
the cases reported by Lewin and Zclekauer. In Lew- 
in's case, inhalations of chloride of iron were used to 
arrest a hemorrhage from the lungs. The patient soon 
afterward died, and little particles of iron were found 
by Schulz, the chemical assistant of Frerichs, in a cav- 
ity in the upper lobe of the right lung.* In the simi- 
lar case of Zdekauer,f the Russian professor, assisted 
by Holm, detected a far larger quantity of iron every- 
where in the tissue of the lung than appertains to the 
blood it contains. 

* Inhalations Therapie, p. 190. 

f Quoted in Wiener Med. Woclienschrift, 1861, No. 30. 
5 



46 INHALATIONS IN THE TREATMENT 

These facts, some of which were elicited and dwelt 
upon in the report and discussion before the French 
Academy, and which convinced, as we may judge by 
the adoption of all the points of the report, that critical 
body of the penetrability of atomized fluid, can leave, 
then, no doubt on the subject. But there is another 
matter which it seems to me may be advanced as evi- 
dence, namely, the immediate effect perceived from the 
inhalation of certain articles. For instance, if cold 
water be inhaled, a sensation of cold in the larynx and 
trachea, extending thence into the chest, is very com- 
mon. Many articles in strong solution, and tannin 
may be mentioned among them, give rise to a feeling 
of oppression and of violent burning in the chest. 
From the inhalation of a strong solution of alum, I 
have seen on two occasions asthmatic, wheezing 
breathing very speedily produced, with loud dry rales 
discernible at various parts of the chest; the attack 
lasted for eight or ten minutes. Further may be men- 
tioned what, in a patient under my care, affected with 
bronchorrhcea, I have repeatedly observed, the sense of 
tightness in the chest attended with a very greatly, I 
might say immensely, diminished expectoration very 
soon after inhaling any strong astringent solution, par- 
ticularly of alum or of tannin. 

The question of the pulverized fluids reaching the 
respiratory channels is thus, to any unprejudiced mind> 
no longer one of unbelief. But it still remains to be 



OF THE RESPIRATORY PASSAGES. 47 

solved how much of a given solution arrives there, and 
what proportion finds its way into the deeper textures. 
Again, is the temperature a modifying agent; do chem- 
ical changes take place in the atomized liquid when in- 
haled; and under what circumstances is the passage of 
the spray prevented ? To enter into these questions at 
any length would necessitate long and tedious discus- 
sion, involving allusion to many chemical and physical 
laws. Let me merely state that, though attempted to 
be solved by Waldenburg, with great care, we do not 
know how much of the fluid gets into the respiratory 
structures; and that we shall have to decide its passing 
in any quantity chiefly by physiological and therapeutic 
experiments. Chemical reactions only take place in 
certain articles pulverized, as in sulphurous waters. 
The temperature of the stream varies with the temper- 
ature of the surrounding atmosphere, the apparatus 
employed, the distance of the patient from the spray- 
producing tubes, and the temperature of the fluid to be 
pulverized. Bearing this in mind, we can ordinarily 
regulate the heat of the stream without much difficulty ; 
and in point of fact it must always be recollected that 
it takes very readily and speedily the temperature of 
the surrounding air. Practically, therefore, the subject 
of the temperature of the spray does not occasion much 
perplexity. The spray from a steam atomizer is 
warmer, particularly when inhaled rather near to its 
point of production, and from its comparative warmth 
is generally more acceptable to the person inhaling. 



48 INHALATIONS IN THE TREATMENT 

With regard to the circumstances interfering or pre- 
venting the passage of the spray into the respiratory 
passages, I have already alluded to the intensity of the 
current. I may add that breathing through the nose; 
the tongue not being sufficiently depressed ; the head 
being inclined forward ; and all other postures which 
would change the angles favorable to the progress of 
the pulverized fluid, or interfere with the freedom of 
respiration, are obstructing elements. I have tested 
these points experimentally by letting a man breathe 
an atomized solution of aniline in conditions unfavor- 
able to the entrance of the spray, and have then ex- 
amined him w 7 ith the laryngoscope to obtain a view of 
the discolored laryngeal membrane. I found that 
though he may be kept inhaling steadily for four or 
five minutes, there is scarcely a perceptible alteration 
in color at the beginning of the respiratory passage, 
and it is therefore highly improbable that any of the 
pulverized liquid should have passed lower down. 
Many of the negative experiments, whether on man or 
on animals, have been, I think, clearly due to a neglect 
of the points mentioned. 

It w r as necessary to discuss these hindering causes, 
because it was necessary to indicate in how far we 
could guard against them, and while showing that 
they might explain some of the discrepancies of differ- 
ent observers, to make evident their bearing in estima- 
ting the effects of medicines employed by inhalation. 



OF THE RESPIRATORY PASSAGES. 49 



CHAPTER IV. 

DOSES OF MEDICINES FOR INHALATION. 

The question of doses is one far from easy to de- 
termine, and can only be fixed experimentally — can, in 
other words, only be settled by a careful study of res- 
piratory therapeutics, in which due importance is at- 
tached to the sources of fallacy already indicated, and 
in which they are avoided. Moreover, the dose varies 
with the apparatus ; or rather, though the dose be the 
same, to obtain that dose in the mouth we may have to 
use more of the medicated fluid or a stronger solution 
with one atomizer than with the other. Thus, in the 
apparatus of Bergson, it takes, according to a calculation 
of Lewin — whose own glass atomizer is, however, still 
more wasteful of the medicated liquid — eight ounces of 
fluid, which quantity can be pulverized in from twelve 
to fourteen minutes, and of which three-eighths only 
arrive at the mouth, even when the patient is suitably 
near to the spray- producing tubes ; a point of course 
which also influences the estimate of doses. To insure, 
therefore, three ounces of spray reaching the oral 
cavity, we must use an amount of solution nearly three 
times the dose required. With the hand-ball atomizer 

5* 



50 INHALATIONS IN THE TREATMENT 

with fine spray tubes, I do not think the quantity 
lost is nearly as great; with ordinary care, and placed 
rather close to the patient, fully three-fourths reach 
the mouth. In Siegle's steam apparatus, one ounce is 
atomized in about twelve minutes, and perhaps not more 
than a fourth is lost, but the steam dilutes the solution 
prepared by nearly one-half; a solution in the cup of 
ten grains to the ounce would therefore be reduced by 
the vapor to between five and six grains to the ounce, 
and of this about four grains would be really inhaled 
through the mouth. 

Speaking generally, the dose to be given does not 
vary materially from that employed internally. But, 
with reference to narcotics, this does not hold good, as 
they are readily absorbed and act efficiently in smaller 
doses. Concerning astringents, too, though they are 
often employed in doses approximating in their strength 
those for external use, when designed to reach the 
deeper structures, we must, bearing in mind the deli- 
cacy of these textures, carefully graduate the dose. 
Any agent which is soluble in water, or in a watery 
infusion of an aromatic, or in very dilute alcohol, can 
be used by an atomizer. Substances soluble in glyce- 
rin, or capable of being suspended in thin emulsions, 
may also be employed, but not, as a rule, satisfactorily. 
I now subjoin a table, in which the dose is calculated 
to the ounce of water, for any form of steam atomizer 
throwing a fine spray. It represents the articles which 



OF THE RESPIRATORY PASSAGES. 51 

have been most em ployed, and there is scarcely one in 
the table that I have not used in the doses mentioned. 
Where the dose is not stated from personal knowledge, 
or where a particular kind of application is alluded to, 
I have added the name of the observer. I have also 
indicated the pathological conditions to which the doses 
are suitable. 

TABLE OP DOSES FOE INHALATION. 

ALUM, 10 to 20 Grains. — In this dose suitable to chronic 
catarrhal affections of pharynx and air tubes, particularly in 
bronchial affections with excessive secretion, when, as in most 
inflammatory conditions of the respiratory mucous membrane, 
it may be advantageously united with opium. In rather larger 
doses, 30 grains to the ounce, useful in pulmonary hemorrhage. 
Is, as an astringent, generally more of a sedative and more 
suited to conditions of irritation than tannin. (Fieber.) 

TANNIN, 1 to 20 Grains. — Useful for the same affections 
as alum. Employed in cases of laryngeal ulceration and ex- 
crescences, in oedema of the glottis (Trousseau), in croup. 
Here, as well as in pulmonary hemorrhages, in large doses. 
In ordinary cases of laryngeal or bronchial disease, begin 
with a small dose. If the remedy occasion much heat and 
dryness, it is not to be employed. 

IEON (perchloride of), ^ to 2 Grains. — In earlier stages of 
phthisis. In chronic pharyngitis or laryngitis may be used 
stronger. As a weak inhalation in hysterical aphonia. Of 
greatest strength in pulmonary hemorrhage, 2 to 10 grains 
to the ounce, or 10 to 40 m. of Monsel's salt to the ounce. 
The lactate, citrate, or phosphate may, in ordinary cases, in 
which we wish a non-astringent salt of iron, be also used, 
though they are not, on the whole, as available as the chlo- 
ride. 



52 INHALATIONS IN THE TREATMENT 

NITRATE OF SILYER, 1 to 10 Grains.— In ulcerations 
of pharynx and larynx, in follicular pharyngitis. A face 
shield is always to be used. 10 grains to the ounce only in 
cases of ulceration. 

SULPHATE OF ZINC, 1 to 6 Grains.— In bronchial 
catarrh with excessive secretion. In aphonia, connected with 
chronic laryngeal catarrh. 

CHLORIDE OF SODIUM, 5 to 20 Grains.— Promotes 
expectoration and diminishes sputa ; and employed in phthi- 
sis. 

CHLORINATED SODA {Liquor Soda* Chlorinatce), £ 
to 1 Drachm. — In bronchitis, with offensive and copious ex- 
pectoration ; in phthisis. 

CHLORATE OF POTASSA, 10 to 20 Grains.— In 
chronic catarrhal laryngitis and bronchitis. In subacute or 
chronic laryngeal and pharyngeal congestion, particularly 
when attended with a feeling of dryness. 

MURIATE OF AMMONIA, 10 to 20 Grains.— In laryn- 
geal and bronchial catarrh, acute as well as chronic. To 
promote expectoration; also in capillary bronchitis. The 
dose best borne is not above about 10 grains to the ounce, 
though as much as two drachms to the ounce have been em- 
ployed. (Siegle.) 

OPIUM (watery extract of), | to | a Grain. — In irrita- 
tive coughs, and as an adjunct to allay irritation. Also for 
its constitutional effects. Dose of tincture of opium 3 to 10 
drops. Acetate of morphia one-twelfth to one-eighth of a 
grain has been administered, but large doses require much 
caution. 

CONIUM (fluid extract of), 3 to 8 Minims.— Irritative 
cough; asthma; feeling of irritation in larynx, 

HYOSCYAMUS (fluid extract of), 3 to 10 Minims.— Spas- 
modic coughs; whooping-cough. One-half a grain of the 
extract, gradually increased, or the tincture may be em- 
ployed. 



OF THE RESPIRATORY PASSAGES. 53 

CANNABIS INDIOA (tincture of), 5 to 10 Minims.— In 

spasmodic coughs ; phthisis. 

IODINE [Liq. Iodinii Compos.), 2 to 15 Minims. — In 
chronic bronchitis ; in phthisis. 

ARSENIC [Liq. Potass. Arsenzt), 1 to 20 Minims.— 
Nervous asthma. (Trousseau.) 

TAR-WATER, 1 to 2 Drachms of officinal solution.— In 
offensive secretions from bronchial tubes ; in tuberculosis ; 
as an antiseptic in gangrene of lungs. 

TURPENTINE, 1 to 2 Minims.— In chronic bronchitis 
with offensive secretions; in bronchorrhcea ; in gangrene of 
lungs. 

LIME-WATER, used of officinal strength, or stronger.— 
In diphtheria; in membranous croup. 

WATER ; Distilled. — Cold, in pulmonary hemorrhage. 
Warm water in asthma, in croup, in bronchitis. 

It is always preferable that the solutions should be 
made by the addition of distilled water; and it saves 
much annoyance in the working of the atomizer if some 
of them — for instance, those of tannin — are strained. 
In some cases the dose recommended cannot be borne 
at first. It is, indeed, always best, excepting if the 
prompt action of a narcotic be needed, to begin with 
small doses, and educate, as it were, the respiratory 
mucous membrane to tolerance. 

What has been stated applies only to doses for 
atomization. The quantities for the ordinary inhaler 
or where gases are inhaled cannot be so accurately 
fixed. I have used tincture of iodine one drachm to 
the pint of hot water in cases of chronic bronchitis and 



54 INHALATIONS IN THE TREATMENT 

of early phthisis, without seeing, however, any decided 
effects from it. Carbolic acid may be employed in the 
same strength and several times daily, with, I think, 
appreciably fair results in chronic bronchitis and to 
further expectoration. It is not necessary, of course, 
to change the solution each time the inhalation is re- 
sorted to. Pouring boiling water on tar in about equal 
proportions, or in cases of susceptible mucous mem- 
branes in less strength than this, and using the inhala- 
tion twice a day or oftener, ten minutes at a time is 
of service for the same purpose, and has been even 
recommended in tubercular cases. It was by pour- 
ing the essence of turpentine upon boiling water and 
directing the patient to inhale the vapor for fifteen 
minutes every two hours that Skoda obtained the 
recovery of the cases of gangrene of the lungs he 
published. 

Chlorine and iodine gas cannot be inhaled unless 
diluted with air. The inhalation of chlorine recom- 
mended by Pancoast, in cases of catarrhal aphonia with 
subsequent debility of the cords, was effected with an 
ordinary glass retort and a glass funnel, having some 
filtering paper at the bottom. In the bowl of the retort 
was placed a solution of chloride of sodium or lime, 
and in the glass funnel a weak solution of sulphuric 
acid in water. As the dilute acid fell drop by drop 
into the bowl of the retort, chlorine was very gradually 
liberated and breathed from the end of the instrument. 



OF THE RESPIRATORY PASSAGES. 55 

The inhalations were repeated two or three times a day ; 
each lasted a few minutes.* 

Various means have been suggested to obtain the 
fumes of muriate of ammonia, which has been much 
lauded in chronic bronchial affections. One of the sim- 
plest is suggested by Pasch. It consists in putting a 
drachm of liq. ammoniae in a saucer, and placing in 
this a watch-glass with about half a drachm of pure 
muriatic acid. White fumes of muriate of ammonia 
arise, which may be inhaled through a paper funnel. 

Of all the gases oxygen is now being most tried, par- 
ticularly for the relief of dyspnoea and in low fevers, 
or during convalescence from low fevers, and in chloro- 
sis. We must await these new trials ; for the former 
experiments were unsatisfactory. But excellent results 
have quite lately been claimed for oxygen inhalations 
by Demarquayf — who is at present investigating the 
subject — not only in the conditions named, but in dia- 
betes, in senile gangrene, and in prolonged suppuration. 
The gas is inhaled pure; and may be generated by any 
of the processes known to chemists. Several appara- 
tuses for its convenient and speedy production have, 
however, been recently brought forward ; and one of 
the kind has been patented by Dr. Beigel. The appa- 
ratus made by Galante in Paris is very well arranged. 

* Transactions of the Am. Med. Association, vol. iii. 
f See Reports to Acad, of Medicine; and Gazette Medicale, 
1866. 



5G INHALATIONS IN THE TREATMENT 



CHAPTER V. 

THERAPEUTIC CONSIDERATIONS. 

As the mode of using inhalations and the general 
questions connected with their employ have now been 
considered, we may turn to the more strictly clinical 
part of the inquiry, and examine, by the light of ob- 
servation, into their real value as therapeutic means. 
In so doing I shall only be able to discuss the appli- 
cability of the atomized fluids to the treatment of some 
of the principal diseases of the respiratory organs; for 
to do otherwise would be to write a treatise on respi- 
ratory therapeutics rather than an essay bearing on 
the subject. Nor can I introduce in detail all the 
material I have collected even on the matters brought 
forward, but shall allude only to such parts of it as are 
the most significant, embodying, however, all in any 
deductions made. 

And first, to look at laryngeal affections. Here I 
have found atomized liquids of most service in the 
catarrhal conditions, whether connected with pharyn- 
gitis or not. In the loss of voice and irritative cough 
associated with catarrhal laryngitis, not, however, 
while in its most acute stage, I have repeatedly known 



OF THE RESPIRATORY PASSAGES. 5? 

inhalations of alum, about ten grains to the ounce, com- 
bined with five to six drops of laudanum, or with co- 
nium, produce a most happy and soothing effect, and 
exert sometimes an almost immediate influence on the 
voice. Thus, in a case of ten days' standing, in an 
elderly gentleman, the voice became after each inhala- 
tion, two to three being employed daily, quite distinct, 
though at first it resumed its whispering tone between 
them. In a few days a permanent result was percep- 
tible. I have obtained an equally good result from a 
solution of chlorate of potassa. The soothing effect of 
the remedy in one case particularly in which a high de- 
gree of both pharyngeal and laryngeal congestion of 
upwards of a week's duration existed was very marked. 
Inhalations of pulverized warm water, with or without 
narcotics, are very grateful in the acute or subacute 
catarrhal conditions, since they relieve much the sense 
of dryness and of heat. 

In the more chronic cases, and when marked swell- 
ing of the mucous membrane of the larynx and vocal 
cords is perceptible, the effects of inhalations of atom- 
ized fluids are not always quickly evident ; but in 
these cases, too, I have used alum, tannin, sulphate of 
zinc, and the subsulphate of iron, with advantage, com- 
mencing with small doses. For instance, I was con- 
sulted by a clergyman who had strained his voice by 
incessant speaking, and had in addition caught a severe 
cold. His voice, from having been one of remarkably 

6 



58 INHALATIONS IN THE TREATMENT 

fine compass, had become coarse, and was at times so 
hoarse as to be whispering. The laryngeal mucous 
membrane was much congested, and there were a few 
rales in the chest from accompanying bronchitis. He 
coughed much, complained of an uneasiness in the 
throat, and was rather short of breath; otherwise no 
symptoms of any disorder existed. He had tried for 
three or four weeks various internal medication, with- 
out benefit. I directed him inhalations of tannin, five 
grains to the ounce, subsequently somewhat increasing 
the strength. After the sixth inhalation his voice im- 
proved most strikingly, and it continued to improve for 
ten days, at which time he left the city. When not 
endeavoring to speak too loud, the voice w r as quite 
clear, and had nearly regained its natural tone ; the 
cough had almost ceased. 

From the subsulphate of iron I have seen similarly 
good and even prompter effects. Not long since I 
emplo} r ed it in a case in which great swelling of the 
epiglottis existed, concealing to a very considerable 
extent the structures within the laryngeal aperture, 
and attended with much difficulty in swallowing and 
aphonia. The disorder had lasted for more than two 
months, and the loss of voice had been gradually pro- 
gressing, until, five clays before I saw the patient, the 
voice had been reduced to a mere whisper. Several 
drachms of a solution of MonsePs salt, sixteen minims 
to the ounce, were injected by a hand-ball atomizer, 



OF THE RESPIRATORY PASSAGES. 59 

and before the young man left the office his voice was 
distinctly audible. He came back two days afterward, 
speaking quite plainly, and stating that he had been 
able to swallow solid food, the first for weeks. The 
inhalation was repeated, and both voice and power of 
deglutition again markedly improved. Subsequent 
examination with the laryngoscope showed the most 
evident reduction in the tumefaction and change in the 
color of the engorged structures. 

In the various forms of ulceration of the laryngeal 
structures, the method of treatment under discussion 
has been applied by means of pulverized solutions of 
tannin, of corrosive sublimate, of iodine, of iodide of 
silver and of nitrate of silver. I have used tannin, 
sulphate of copper and nitrate of silver in several 
cases, but have not obtained good results. For exam- 
ple, in a gentleman, forty-two years of age, on whose 
right false vocal cord the laryngoscope detected an 
ulcer with irregular borders, inhalations of the com- 
pound solution of iodine, commenced with 10 drops to 
the ounce and gradually increased, were faithfully 
tried for fully three weeks without any perceptible ben- 
efit being produced. Subsequent touching with nitrate 
of silver, the hand being guided by the reflected image 
of the parts in the laryngeal mirror, proved far more 
effectual, both in the improvement manifest in the 
ulcer and in the symptoms of impairment of voice, 
difficulty in swallowing, and cough. The ulcer, judg- 



60 INHALATIONS IN THE TREATMENT 

ing from the history of the case, was probably scrofu- 
lous. In the following case of laryngeal ulceration the 
treatment by inhalation was also fully tried : 

A man, forty-five years of age, was admitted into 
the Pennsylvania Hospital on the 13th of February, 
1866, with a cough which he traced to exposure dating 
eight weeks back, though when questioned he stated 
that he had a very slight dry cough, off and on, 
for a month previous to this. The severe cough ac- 
companying the cold he had caught was attended with 
sore throat, and soon afterward with hoarseness. On 
admission he was noted to be pale and to present a 
sickly aspect; respirations 24; expectoration but slight 
in quantity, tough and whitish ; and neither fever nor 
deficient appetite. No abnormal physical signs were 
discernible in the lungs, save a slight harshness at the 
lower part of the left. There was difficulty in swallow- 
ing, without pain on pressure over the larynx; the 
voice was hoarse, but not completely lost; the fauces 
were not reddened. On laryngoscopic examination a 
large superficial, yellowish ulcer was seen on the right 
false vocal cord, extending to the arytaeno-epiglottidean 
fold. There was also considerable thickening of these 
structures as well as those of the left side, but the true 
cords seemed unaltered and approximated fully in the 
act of vocalization. The man denied the existence of 
any syphilitic taint. 

On the 26th of the month, having since his admission 



OF THE RESPIRATORY PASSAGES. 61 

had his larynx touched several times with nitrate of 
silver, besides taking tonics, he was directed to use 
daily inhalations of alum, 30 grains to the ounce. On 
the 9th of March this treatment was stopped, and he 
complained of his throat feeling very sore — an occur- 
rence which, with a sense of oppression and tightness 
and an aggravation of the cough, I have several times 
noticed from the use of very strong solutions of alum. 
Finding, on examination with the laryngoscope, ulcera- 
tion beginning on the other cord, and perceiving no 
amelioration in any of the symptoms, the alum solu- 
tion was not resumed, but sulphate of copper inhala- 
tions, 2^ grains to the ounce, were substituted. On 
the 18th, as they had produced no effect on the ulcers, 
though the swelling was less, the strength was doubled, 
and he inhaled an ounce of the solution daily without 
any inconvenience, though twice it made him sick at 
the stomach. His general condition was not satisfac- 
tory, and in addition to iodide of iron and an anodyne 
cough mixture, he was placed on cod-liver oil, a table- 
spoonful three times daily. A few days afterward an 
examination of the chest showed coarse, dry rales in 
expiration in both lungs, and a more high pitched per- 
cussion note with greater resistance at the right apex. 
The coarse, dry rales were there, too, more distinct; 
there was more cough, followed by a frothy and copi- 
ous expectoration ; and, altogether, it was evident that 
a tubercular infiltration into the lung was taking place. 

6* 



62 INHALATIONS IN THE TREATMENT 

From this time on the history was that of a well- devel- 
oped case of phthisis. He had much cough and pro- 
fuse expectoration, with rapidly progressing emaciation, 
and then night-sweats. The dry rales gradually dis- 
appeared, giving way to harsh breathing, and a month 
after the date last mentioned signs of softening were 
clearly discernible at the right apex. 

But to return to the larjmgeal symptoms and their 
treatment by inhalations. The inhalation of copper, 
which was kept up until the 26th of March, considera- 
bly lessened the frothy expectoration and somewhat 
reduced the swelling, but it did not put a stop to the 
progress of the ulceration. Nitrate of silver, with a 
brush, was then several times used, and on the 7th of 
April two fluid drachms and a half of a solution of 
nitrate of silver were administered by means of the 
hand-ball atomizer. The injection produced a burning 
sensation, lasting two hours, and a marked abatement 
in the cough. But on the 9th the ulceration, instead 
of decreasing, was found to have extended to the right 
true vocal cord, which was decidedly excavated on its 
margin; a few isolated, yellowish spots were also seen 
on the wall of the trachea. The poor man had much 
difficulty in swallowing, but had not completely lost his 
voice. 

From the 9th to the 16th of April, he took, with the 
steam atomizer, six inhalations of nitrate of silver, 
half an ounce at a time, of the strength of fifteen 



OF THE RESPIRATORY PASSAGES. C3 

grains to the ounce. Twice, after inhaling, he was 
sick at his stomach. Subsequent to each inhalation, it 
was noted that his larynx smarted for an hour; but for 
a few hours the expectoration ceased. From this 
period on until he left the hospital, April 30th, and 
very shortly before his death, the inhalations were not 
regularly kept up. A few local applications were 
made by means of a sponge, and he expressed himself 
always as being relieved by them. His increasing 
weakness caused him to prefer them to inhalations. 
But nothing really gave him much relief; the difficulty 
in swallowing was so great that he had to be nourished 
exclusively by fluids ; there was tenderness on pressing 
between the hyoid bone and larynx; the cough was 
very annoying, and the sputa, no longer so frothy, 
were obviously nummular; the voice was reduced to an 
almost inaudible whisper. The last laryngoscopy 
examination, made after the inhalations had been 
stopped, showed that the ulceration had greatly altered 
the true cords. The false were less swollen, and the 
ulcer on them had not increased, but an ulcer was also 
seen on the outer edge of the left aiytasno-epiglotticlean 
fold. 

In reviewing this singular case, we are struck with 
the sudden beginning of the affection in the larynx and 
with the laryngeal phthisis, preceding that of the lungs. 
But this point of the case cannot be here discussed. I 
have introduced it rather to studv the effects of the 



64 INHALATIONS IN THE TREATMENT 

inhalations ; and though these were, on the whole, of 
some service in reducing the swelling, and though thus 
we may claim that a certain degree of comfort was pro- 
cured, it cannot be said that either the sulphate of cop- 
per or the nitrate of silver arrested the extension of the 
ulceration. ]NT or were the results obtained by the latter 
agent greater than, indeed not so great as, those pro- 
duced by the local application of nitrate of silver with 
a sponge or brush. In simple ulcers, inhalations may 
be of more decided use ; though even here I much 
prefer, so far as I have tested the matter, the other 
method of local treatment. 

In oedema of the glottis tannin has been greatly 
landed by Trousseau. In the first volume of his 
Clinique Medicale he records a case in which a strong 
solution of tannin was inhaled every hour, with the 
most obvious effect on the attacks of suffocation, and 
indeed on the disease. During the second day there 
was but one fit of suffocation, and the respiration had 
lost its noisy character. The attacks recurred once in 
twenty-four hours for three days, but on the fourth day 
of treatment the respiration was natural. The young 
woman left the hospital a few days afterward, perfectly 
convalescent. 

The same treatment, too, proved of service in the 
hands of Barthez,* at the Children's Hospital, St. 

* Traitement des Angines Diphtheritiques par la Pulverization. 
Paris, 1861. 



OF THE RESPIRATORY PASSAGES. 65 

Eugene, in laryngeal diphtheria and in crovp. He 
cites four cases in which a tannin solution, from five to 
ten per cent, strong, was inhaled from eight to twenty 
times in the course of twenty-four hours, each inhala- 
tion lasting from fifteen to twenty minutes, and being 
always followed by evident temporary relief. Two of 
the children recovered, the other two died. But the 
autopsy proved that the false membrane had entirely 
disappeared. Death was due to the diphtheritic poison- 
ing. The results of the tannin inhalation are attributed 
by Barthez to the astringent effects of the tannin on the 
membrane, which, when corrugated, rolls up at the 
edges, and is thus prone to be gradually detached. 
But Fieber, who treated fifteen cases with tannin 
solution much in the same manner, and who reports 
ten cures among them, attributes the success to the 
dissolving influence of the remedy. Yet, when we 
come to, examine critically the instances recorded by 
Barthez, the former supposition becomes far the more 
probable. Thus, in analyzing his cases, I find that the 
first was sick for five days before admission, and seven 
days under treatment, making, so far as can be judged 
from the record, from nine to ten clays that the mem- 
brane lasted. In the second case the treatment did not 
begin until the second clay of the sickness; the child 
died on the twelfth clay. In the third case, which seems 
to have been one of pseudo-membranous croup rather 
than of laryngeal diphtheria, the treatment commenced 



66 INHALATIONS IN THE TREATMENT 

on the fourth day of the malady, and by the ninth day 
the little patient had recovered. The fourth case was 
eight clays sick when the treatment by inhalation began, 
and was subjected to it for four or five days before full 
recovery took place. Now this does not look like any 
marked solvent power of the remedy, for diphtheritic 
membranes are not permanent structures, but are very 
apt to disappear from the circumference to the centre 
within a week after their appearance. Hence, if we 
accord any value to the treatment — which, bearing in 
mind the usually fatal character of laryngeal diphtheria 
and the grave character of pseudo-membranous croup, 
we cannot totally refuse to do — we must also admit 
that the action is not rapid, and not what we might 
expect from a solvent. Nor can we overlook the effect 
of the water in the combination as a cleansing agent, 
and as tending to aid in removing and in expectorating 
the breaking down textures; for Siegle* used inhala- 
tions of pulverized warm water alone in a case, appar- 
ently hopeless, of membranous croup, with the greatest 
relief to the child, and with the result of causing it to 
expectorate with the dense mucus shreds of the mem- 
brane. The child recovered. 

But to return to diphtheria. Other agents besides 
tannin have been resorted to, to counteract its local 
manifestation, both when the larynx is implicated and 

* Hals und Lungenleiden, 1865. 



OF THE RESPIRATORY PASSAGES. 67 

when the membrane has not extended to it — chloride of 
iron, chlorate of potassa, alum. Lewin* has reported 
at length fifteen cases, eleven of which recovered. I 
have analyzed these cases, and find the following result. 
Only in four of the eleven that recovered (Cases IV. ; 
VI., VII. , and XL) was the larynx implicated, and in 
these four the membrane was chiefly on the upper sur- 
face of the epiglottis. Only in one, Case XL, did 
it extend to the under surface of the epiglottis and to 
the arytenoid cartilage. Of the four fatal cases the 
larynx was in three very decidedly affected. This 
result is therefore by no means remarkable, particularly 
as cauterizations and internal remedies were at the 
same time used. Indeed Lewin himself speaks more 
of the action of the inhalations in preventing the mem- 
branes from re-forming than of their power to remove 
those already formed. 

Yet another remedy that has been recommended, 
both in diphtheria and in croup, is lime-water. Kiich- 
enmeister and others have found that the pseudo-mem- 
brane was soluble in concentrated acetic acid, in alka- 
lies, in carbonate of lithia, but with greatest readiness 
in lime-water, and the attempt has been made to em- 
ploy this by atomization as a solvent. Biermerf was 
the first to use it. The patient was a girl, aged seven- 



* Inhalations Therapie, 1865. 

f Schweizersche Zeitung fur Heilkunde, 1864. 



68 INHALATIONS IN THE TREATMENT 

teen, admitted into the hospital at Berne for croup, 
which had lasted for four days; the suffocative phe- 
nomena were very marked. To moisten the respira- 
tory passages pulverized water was tried, first warm, 
then boiling. After inhaling for an hour, with much 
comfort, vehement coughing occurred, whereby a quan- 
titv of mucus and shreds of false membrane were 
discharged, causing decided relief. This became still 
more evident when warm lime-water (one part of lime 
to thirty of water) was used with the nebulizer every 
second hour, each inhalation lasting a quarter of an 
hour. Thick, purulent matter and crumbling pieces of 
membrane were expectorated, and the signs of laryn- 
geal obstruction gradually disappeared. 

Bieriner insists on the necessity of using the inhala- 
tions hot. Dr. Kuchenmeister and Dr. Brauser* have 
each published a successful case treated in the same 
manner, and a substitute for the pulverized inhalation 
has been attempted in this country by Dr. Geiger, who 
poured hot water on unslacked lime, and caused the 
steam arising from it to be inhaled. He reports 
several cases of pseudo-membranous croup with a 
fortunate issue, f 

Not having tried atomized lime-water in croup or 
in laryngeal diphtheria, I cannot speak from personal 

* Referred to in British and Foreign Med,-Chir. Review, July, 
1 865. 

f Medical and Surgical Reporter, April, 1866. 



OF THE RESPIRATORY PASSAGES. GO 

experience either of its effect or want of effect. But I 
have watched in two cases of diphtheria, w 7 ith some 
care, the action of lime-water on the visible deposits. 

In the first case, that of a lady, seen in consultation 
with her physician on the fifth clay of her confinement, 
the deposit covered the roof of the mouth, the half 
arches and part of the w T all of the pharynx. There was 
also, and indeed the progress of the case placed the 
matter beyond doubt, reason to believe that nasal diph- 
theria existed. She was taking chloride of iron, full 
nourishment and stimulants. I directed a stream of 
pulverized lime-water about eight times stronger than 
that officinal in our pharmacopoeia — the liquor calcis 
saccharatus of the British pharmacopoeia — on the 
affected part, by means of an excellent hand -ball 
atomizer, for three or four minutes at a time. This 
treatment was carried on every few hours, but no per- 
ceptible influence on the membrane could be detected. 
The application was cleansing and very grateful, par- 
ticularly so when thrown up the nostril. And here 
let me, in passing, state that the spray was felt to 
arrive in the throat, and that though the remedies we 
resort to may not succeed in dissolving the membrane, 
I beg to draw attention most earnestly to this use of 
the atomizer in nasal diphtheria, and particularly in the 
nasal diphtheria of children, as an excellent means of 
acting locally on the affected part. But to return to 

1 



70 INHALATIONS IN THE TREATMENT 

the case. It terminated fatally, the membranes in the 
mouth remaining in a very thick layer. 

The second case was that of a gentleman, thirty- five 
years of age. Here there was no nasal diphtheria, nor 
were the constitutional symptoms by any means so 
grave; and after the disappearance of the membranes, 
which took place in about nine days, convalescence was 
rapid. As local treatment, early in the affection, a 
strong solution of sulphate of copper was employed. 
But I also, both at the time and afterward, made use 
of atomized solutions of lime, in the same manner as 
in the preceding case, and not hot. The remedy was 
again very grateful and cleansing; yet, though I 
selected repeatedly the same spot on the left half arch 
to throw the solution on, I could not see that it had 
any perceptible effect in thinning the deposit. 

If lime-water, then, be a solvent of the membrane on 
living textures, it is so very gradually, and much of it 
would have to be employed to produce a decided result. 
In cases running an acute course it could therefore not 
be depended on. Indeed, to take Prof. Biermer's case 
as an example, how much may have been due to the 
inhalation of the warm fluid alone ? That warm water 
by itself is serviceable we know from Siegle's case, 
already mentioned. 

In hooping-cough, Dr. Steffen* claims to have had 

* Journal fiir Kinderkrankheiten, Jan. and Feb., 1866. 



OF THE RESPIRATORY PASSAGES. Yl 

success with an inhalation of common salt and opium, 
and with five grains of tannin and three drops of lauda- 
num in two ounces of water, used daily. But though 
the inhalations seemed to have afforded some comfort 
to the children, the duration of three of the cases was 
from two to three weeks, and one case lasted nine 
w T eeks. Hyoscyamus, alum, and perchloride of iron 
have also been employed in this disorder. 

In asthma, arsenic has been recommended by several 
physicians, Trousseau and Eck among them. Chloride 
of sodium with laudanum has also been employed; and 
I have used lobelia and conium in several instances. 
All these remedies except the arsenic are chiefly re- 
sorted to at the time of the paroxysm. But I cannot 
say that I have seen anything produce decided results. 
The inhalation of pulverized warm water alone has 
seemed to me quite as grateful to the patient as medi- 
cated solutions, and has promoted expectoration. 

Turning now to pulmonary affections, we shall in- 
quire into the effects of inhalations on bronchitis, phthi- 
sis, and hemorrhage from the lungs. In acute bron- 
chitis, inhalations of pulverized warm water will often 
afford much comfort and assist in inducing expectora- 
tion. Medicated inhalations I have not used, nor do 
they seem to have been much resorted to. But in 
chronic bronchitis it is evident that they have a large 
field for employ, and the results are sometimes very 
striking;. To cite a case. 



12 INHALATIONS IN THE TREATMENT 

Mrs. , 48 years of age, consulted me in January 

for a cough which she had had for upwards of a year 
and a half. Getting much better during the earlier 
summer months, she had, in the autumn of last year, 
after severe and prolonged exposure to wet, a violent 
bronchitis, or broncho-pneumonia, attended with proba- 
bly much pulmonary congestion, and shortly followed 
by a hemorrhage. She stated that her cough was very 
distressing; the expectoration purulent, profuse, having 
an unpleasant odor. Moreover, it had contained blood 
daily, for several months, varying in quantity from mere 
streaks to an amount which gave to the whole sputum 
in the cup a decidedly bloody appearance. Her breathing 
was oppressed ; at times so much so as to be wheezing 
and asthmatic. Examining the lungs, they were found 
to be rilled with rales, dry and moist, the latter far pre- 
ponderating. There was no decided dulness on per- 
cussion, though at the upper part of the right lung an 
impairment of resonance existed, which may have been 
due to the partial consolidation of the pulmonary tissue 
occurring at the time she had the attack of bronchitis 
or broncho-pneumonia, subsequent to the exposure 
alluded to. The appetite was good ; the general health 
excellent. As she had tried many remedies faithfully, 
some under the advice of an eminent physician, I de- 
termined to use atomized fluids by inhalation, and 
directed an ounce of a solution of alum, 15 grains to 
the ounce, with 6 drops of fluid extract of conium. 



OF THE RESPIRATORY PASSAGES. 73 

The first inhalation produced not only no relief, but a 
decided constriction in the chest; the second, taken 
the next day, led to a severe paroxysm of difficult 
breathing. Finding the astringent action of the 
remedy too great, I reduced its strength to about 8 
grains to the ounce. She bore this perfectly well, 
and after the third inhalation, counting in the first 
two, a change in the sputum was noticeable. It was 
somewhat less copious, and the quantity of blood in it 
was obviously diminished. She took altogether, while 
in Philadelphia — of which she was not a resident — 
nine inhalations, and when she left the citv, though 
the expectoration was still very copious and as yet but 
slightly changed in character, it no longer contained a 
trace of blood. 

During her stay here little or no internal treatment 
was employed ; but on leaving, while urging her to 
continue her inhalations by the atomizer, and to vary 
them at times by breathing the vapor of tar, I also 
directed her chest to be painted with croton oil, and 
gave her a cough mixture, of which wine of tar and 
fluid extract of wild cherry formed the chief ingre- 
dients. 

This treatment was carried on for fully two weeks, 
when I was informed, by letter, that she had used the 
common inhaler with tar and warm water twice each 
day, that she had finished her cough mixture, had em- 
ployed the alum inhalation daily, and that she still 

7* 



74 INHALATIONS IN THE TREATMENT 

had " slight turns of wheezing on lying down, which 
lasted from half an hour to an hour, but none so bad 
as that one in Philadelphia, and they are somewhat 
relieved by inhaling hot camphorated water. The ex- 
pectorations are all, or nearly all, from 4 or 5 a.m. to 
10 a.m. After that there is but little cough. The ex- 
pectoration last week was for a day or two offensive, 
but is very little so now. It is lighter colored, and 
has not been at all bloody since we returned." 

After this, for six weeks daily, she went on steadily 
with the alum inhalations, increasing the strength to 
20 grains or somewhat upwards to the ounce of water. 
She also resorted occasionally to the ordinary tar inha- 
lations alluded to, and at times to pulverized solutions 
of common salt, The cough medicine was abandoned 
and wine of tar taken, though this was not persevered 
in ; the alum inhalations were her main dependence. 
Under this treatment she gradually recovered : the 
cough and all expectoration ceased ; the asthmatic 
seizures no longer took place, and when I saw her in 
Philadelphia, in April, she had been for several weeks 
perfectly well. She had at that time some rales in her 
chest, and a very slight expectoration from a catarrhal 
condition of a few clays' standing, but otherwise she 
presented all the signs of good health. The partial 
dulness under the right clavicle had all but disap- 
peared. 

This case is certainly very interesting as regards the 



OF THE RESPIRATORY PASSAGES. 75 

use of inhalations. The unfavorable consequences at 
first from the too strong solution of alum employed ; 
the speedy disappearance of blood from the sputum ; 
the gradual cessation of the expectoration ; the slight 
general treatment made use of— and to no portion of 
which does it appear that any decided importance can 
be attached — are all decided features in the case. And 
though we may affix some value to the inhalations of 
chloride of sodium and of tar, yet it is evident that the 
most efficient remedy was the alum. 

Besides this remedy, good results may be obtained 
from the use of tannin, of sulphate of zinc, of iodine, 
and, where we wish to promote the expectoration, of 
muriate of ammonia or of chloride of sodium — to all of 
which a small quantity of a narcotic solution can be 
serviceably added. Yet these agents are not always of 
advantage. The extent of the alteration of the mucous 
membrane has a great deal to do with the success of 
the treatment. I have a gentleman under my care who 
has had chronic bronchitis, with excessive secretion, for 
twelve years, scarcely influenced by the various climates 
which he has sought. In his case inhalations of iodine, 
of tannin, of carbolic acid, of lobelia, of sulphate of 
zinc, of alum, of muriate of ammonia, of chloride of 
sodium, have thus far been used to little if any pur- 
pose. 

There is no disease for which inhalations are more 
likely to be eagerly resorted to than phthisis. I have 



76 INHALATIONS IN THE TREATMENT 

employed them and noted their effects with care in 
quite a large number of cases ; but it is impossible here 
to give more than the general results, and in so doing 
it will be convenient to separate the effects of the inha- 
lation on the disease itself and on its more prominent 
symptoms. I will take for analysis ten cases, treated 
at the Pennsylvania Hospital, and in which either no 
other remedies were prescribed, or merely remedies to 
fulfil a temporary indication. In four cases chlorinated 
soda was used, the liquor sodae chlorinates of our phar- 
macopoeia. It was employed every day, in doses vary- 
ing from half a drachm to a drachm to the ounce ; or 
sometimes two inhalations were administered daily, of 
half a drachm each. In the doses mentioned it was 
perfectly well borne, and although at first it irritated 
and had to be given in a more diluted form, after a few 
days it was taken without difficulty. In the first case — 
a case in which softening was just beginning — the in- 
halations were used daily for eighteen days. They 
caused no difference either in the physical signs or 
symptoms, though the patient stated that he coughed 
less and that the expectoration was much easier after 
them. In the second case the effect on the cough was 
similar, and the sense of tickling in the throat, for which 
the patient had previously tried several remedies in 
vain, was quickly relieved. A decided improvement 
also took place in her general condition ; but the same 
dulness under the right clavicle, with crackling, which 



OF THE RESPIRATORY PASSAGES. 77 

existed at the beginning of the treatment, was found 
after she had for twenty-two days inhaled daily a solu- 
tion of the strength of one drachm to the ounce. On 
the whole, however, the remedy appeared to have a 
beneficial influence. In the third case twenty-five daily 
inhalations were used. The cough improved. The dis- 
ease, which had not advanced to softening, remained 
stationary. But neither physical signs nor general con- 
dition showed any decided amelioration. In the fourth 
case the chlorinated soda was not used very long and 
produced no appreciable effect. 

The results in these cases were not particularly en- 
couraging, though not totally negative. Two cases 
were then treated with iodine inhalations ; liquor 
iodinii compositus, viii minims to §j increased to xv 
minims to §j taken daily or twice daily. Both im- 
proved — one strikingly. This was a case of tubercular 
disease of both lungs, following right-sided pleurisy. 
There was crackling (not, however coarse) at both 
apices, and he was losing flesh and strength rapidly, 
notwithstanding that he was taking cod-liver oil and 
iron. The cough was dry and irritative. He used 
every day, for a month, iodine inhalations, at first 
eight minims in each, then fifteen minims morning and 
evening. The internal treatment was stopped. He 
gained several pounds of flesh; his appetite became 
good; the respirations came down to 18, the night- 
sweats ceased, and an undoubted change took place in 



78 INHALATIONS IN THE TREATMENT 

the physical signs; the crackling almost disappeared, 
the dulness lessened. The inhalations at first pro- 
duced some irritation and a little cough. They were 
always followed by slight expectoration. 

Solution of chloride of iron was used in two cases. 
In the one there was coarse crackling, with distinct 
blowing and rather low-pitched respiration under the 
right clavicle, and coarse crackling on the left side; the 
symptoms were those of phthisis passing into the stage 
of softening. One-eighth of a grain of perchloride of 
iron was used morning and evening for sixteen days. 
It rather reduced the expectoration, but did not influ- 
ence the progress of the disease. In the second case the 
effects were decidedly beneficial. When admitted into 
the hospital there was dulness on percussion, with 
harsh breathing under the left clavicle; hacking cough 
of several months' standing; great pallor and marked 
anaemia, which may, however, in great part at least, 
have been due to a severe attack of menorrhagia. 
The pulse was 108; the respirations 26. The perchlo- 
ride of iron was administered in the same way as in 
the preceding case. In a week after she had com- 
menced it, the lips were of far better color, and she 
began to gain flesh and strength. The dose was, after 
seventeen days, increased to one-half a grain daily, 
which she took for ten days, all the time improving. 
For a short period a solution of pyrophosphate of iron 
was substituted, but she went back to the chloride. 



OF THE RESPIRATORY PASSAGES. 79 

The iron inhalations were used for about six weeks, 
and shortly before leaving the hospital her cough had 
all but disappeared. There was a scarcely appreciable 
difference in the percussion note between the two sides 
of the chest, and the respiratory murmur had lost its 
harshness. She did not feel quite so strong and well 
as ten days previous, in consequence of an attack of in- 
termittent fever. I have heard that since she left the 
hospital she has had two hemorrhages. 

In the two remaining cases out of the ten, chloride 
of sodium and muriate of ammonia were chiefly em- 
ployed. They were not without influence on the cough, 
and on the expectoration ; but were apparently no 
check to the disease. 

Thus it will be seen that iodine and iron inhalations 
both had a decided effect where softening had not as 
yet occurred. But did they do so in virtue of any local 
action, or of their general power on the economy after 
being absorbed by the respiratory mucous membrane ? 
This question is one difficult to solve, save by the most 
careful observation of a large number of cases. But 
under any circumstance it would certainly seem- that 
these remedies merit a trial in cases of early pulmonary 
tuberculosis. Supposing the inhalations to be well 
borne and rather comforting to the patient, as they 
mostly are, do we not then introduce desirable medi- 
cines into the system without inconvenience, and by 
carefully making use of the lungs, save the stomach ? 



80 INHALATIONS IN THE TREATMENT 

The foregoing* statements represent the analysis of 
the ten cases, treated under circumstances permitting 
of their careful study ; but they also represent my im- 
pressions derived from a far larger number of cases, of 
which, however, other treatment being at the same 
time employed, so rigorous an analysis could not be 
made. I may also add that I have used carbolic acid 
by atomization in the treatment of phthisis ; yet have 
not seen that it in any way arrested the disease. It 
was rather grateful to the patients, gave them an in- 
creased feeling of comfort in breathing, and had an in- 
fluence in promoting expectoration, and was therefore 
useful ; as indeed it may be even when employed by 
the ordinary inhaler in early phthisis or in chronic 
bronchitis. But I have never seen a case of con- 
sumption arrested by it. 

In turning to the symptoms of phthisis we find, as 
regards the cough, especially when occurring in parox- 
ysms, that pulverized solutions of the watery extract 
of opium, of conium, or of cannabis inclica afford relief; 
and these remedies are particularly serviceable when 
the cough produces vomiting, or is associated with 
great gastric irritability. In cases of cavities with 
purulent contents, or under any circumstances to render 
the sputum more easy of expectoration, solutions of 
common salt or of muriate of ammonia are of avail. 
Where the sputa are copious and offensive, tar has 
been recommended. But judging by the case of a gen- 



OF THE RESPIRATORY PASSAGES. 81 

tleman whose lungs were riddled with cavities, and 
whose expectoration was purulent, profuse, and very 
fetid, tar inhalations pursued in the ordinary manner 
are better, certainly quite as well, borne, and afford 
more comfort. 

As regards hemorrhage from the lungs, the evidence 
that has been collected in favor of the treatment by 
atomized liquids appears very decided. A number of 
cases have been reported by Sales Girons, b} r Lewin, 
by Siegle, by Zdekauer and others, in which, instantly 
after inhalations of strong solutions of alum, or of 
chloride of iron, the hemorrhage stopped. I have 
used alum, chloride of iron, and persulphate of iron, 
and have thought that the remedies had so distinct an 
effect that I should not abstain from resorting to them 
in any case of pulmonary hemorrhage at all unyielding. 
At the same time, as the cases in which the inhalations 
were employed were on active internal treatment, I do 
not bring them forward. There is nothing more diffi- 
cult to establish than the relation between cause and 
effect in haemoptysis. The post hoc propter hoc is here 
so uncertain that evidence, to be accepted, ought to be 
of the most unimpeachable kind. Of my six cases this 
cannot be said. I will, however, state that, contrary to 
w^hat may be expected, the inhalations gave rise to no 
irritation nor coughing or oppression. They may be 
used very strong. In one of the cases alluded to, one 

8 



82 INHALATIONS IN THE TREATMENT 

of our Resident Physicians at the Pennsylvania Hos- 
pital, Dr. Herbert, employed a saturated solution of 
alum; in another, a drachm of Monsel's solution of 
subsulphate of iron to an ounce of water. The cases 
under discussion were all extremely severe. In mere 
spitting of blood, or in instances of blood-streaked 
sputum, the influence of the astringent remedies are 
often very obvious. The case of the lady above re- 
ported, affected with bronchitis, is a case in point. I 
have seen one quite as striking, in wliich two inhala- 
tions of a solution of subsulphate of iron completely and 
permanently arrested a bloody expectoration which had 
lasted for four months. 

Summing up, now, the results of this inquiry, it may 
be stated to lead to these conclusions : 

1. That inhalations by means of atomized fluids are 
an unquestionable addition to our therapeutic means; 
but that they are nothing but an addition, and not a 
substitute for all other treatment; that therefore their 
claims to be so considered are unfounded. 

2. That in most acute diseases of the larynx, and still 
more so in acute disorders of the ]ungs, their value, 
save in so far as those of water may tend to relieve the 
sense of distress, etc., and aid expectoration, is very 
doubtful; though in some acute affections, such as in 
oedema of the glottis and in croup, medicated inhala- 
tions have claims to consideration. 

3. That in certain chronic morbid states of the larynx. 



OF THE RESPIRATORY PASSAGES. 83 

particularly those of a catarrhal kind, and in chronic 
bronchitis, they have proved themselves of value; but 
that they are useless or next to useless in ulcerated 
diseases of the larynx. 

4. That in the earlier stages of phthisis they may be 
of decided advantage, and that at any stage they may 
efficiently aid in treating the symptoms of this malady; 
but that they arc valueless to stay the disease after 
softening has fairly set in. 

5. That their influence on such affections as hooping- 
cough and asthma is not satisfactorily proven. 

G. That they furnish an unexpected augmentation of 
cur resources in the treatment of pulmonary hemor- 
rhage. 

1. That the question in any disease of the respiratory 
tract is not whether the atomized fluids can reach the 
seat of the malady, but whether they can do so in suf- 
ficient quantity, and in a manner to become available 
as a therapeutic means. 

8. That in estimating the action of inhalations of 
atomized fluids, we must accord due value to the ready 
absorption of many through the pulmonary structures, 
and guard against attributing to a local influence what 
may be due to the constitutional effect of the remedy. 

9. That we cannot overlook the part the watery 
vapor plays when using atomized solutions. 

10. That they require much care in their employ; and 
that particularly in acute affections we should consider 

8* 



84 INHALATIONS IN THE TREATMENT 

whether, as they have to be used frequently to be of 
service, the patient's strength justifies the disturbance 
or the annoyance their frequent use may be. 

11. That in any case, to be of service, the inhalations 
ought to be carried on as a treatment with a distinct 
object, and not intermittingly or spasmodically re- 
sorted to. 

These conclusions and the remarks preceding them 
apply exclusively to the treatment of the diseases of 
the respiratory passages by atomized fluids, for though 
incidentally the inhalation of gases or vapors has been 
mentioned, it has purposely been no more than alluded 
to, since this subject has been long before the profes- 
sion and has been often examined ; whereas that of 
inhalations by means of atomized fluids is a novel one, 
and one which will require much unbiased investiga- 
tion to determine its true position. Nor has the appli- 
cability of atomized fluids to affections of the fauces 
been here particularly brought forward ; though, as 
previously indicated, they are of striking value in these 
affections. In many a case of chronic sore-throat I 
have used astringent solutions, as tannin, alum, or solu- 
tions of chlorate of potassa, or sulphate of copper, with 
decided success. In acute sore-throats, or in affections 
of the mouth, sedative and anodyne solutions, or pul- 
verized ice water has often proved most grateful. 
And I have seen elongated and tumid uvulas which 
would formerly have tempted any surgeon to snip 



OF THE RESPIRATORY PASSAGES. 85 

them off, yield to the use of astringent solutions 
thrown directly on them in the form of spray. 

When, now, we contrast inhalation by atomization 
with other kinds of inhalation, we find that by its 
means we can use substances, such as astringents and 
caustics, which were formerly not available. Thus 
this method has greatly extended the range of inhala- 
tions. Moreover, there is very much greater certainty 
of a local action than is otherwise obtainable. As 
regards laryngeal diseases, however, the local applica- 
tion of remedies, guided by the laryngoscope, is on the 
whole more certain and efficient. 

In conclusion, I will point out what a wide range of 
applicability atomization has beyond that to the treat- 
ment of the diseases of respiration, or even of the 
fauces, nares, or any part on which a local action is de- 
sirable. By atomizing salt or iodine in rooms or in 
wards of hospitals, we can cause our patients to 
breathe constantly an atmosphere impregnated with 
these agents, if such an atmosphere be thought desira- 
ble. Permanganate of potassa, chlorine, or carbolic 
aeid may be used in the same manner as disinfectants ; 
and, as I have tested now in many instances, we may 
obtain by atomization the constitutional effects of rem- 
edies on the system. In cases in which the stomach 
cannot be resorted to this will be a great aid. It is 
scarcely necessary to dwell on its value, for instance, 
in anaemia, with enfeebled digestive powers. The 



86 INHALATIONS, ETC. 

effect of remedies, too, thus administered, is generally 
very prompt. I have seen the pupils dilate and a 
staggering gait produced by breathing for a few min- 
utes a pulverized solution of coniuni. Of course it is 
incumbent upon us not to avail ourselves of the respi- 
ratory mucous membrane needlessly; and if it be 
employed, it ought to be done so with care, for it is not 
a membrane that will bear the slights and rude usage 
the stomach receives. But it is a great satisfaction to 
know that, should we wish to make use of the lungs to 
introduce medicines into the system, we possess now a 
means more certain, more efficient, and more suscepti- 
ble of being regulated than any that was formerly 
available. 















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